Provider Demographics
NPI:1124169644
Name:ROQUIZ, GIDEON M
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:M
Last Name:ROQUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6107
Mailing Address - Country:US
Mailing Address - Phone:814-835-2362
Mailing Address - Fax:814-835-2362
Practice Address - Street 1:5205 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-6107
Practice Address - Country:US
Practice Address - Phone:814-835-2362
Practice Address - Fax:814-835-2362
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18457246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA027074Medicare PIN